ASVMEB Order 22055 KARLA LOMBANA, DVM

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BEFORE THE ARIZONA STATE VETERINARY MEDICAL,
EXAMINING BOARD
IN THE MATTER OF: CASE NO.: 22-55

KARLA LOMBANA, DVM
HOLDER OF LICENSE No. 6280

FINDINGS OF FACT,
CONCLUSIONS OF LAW
AND ORDER

FOR THE PRACTICE OF VETERINARY
MEDICINE IN THE STATE OF ARIZONA,

RESPONDENT.

The Arizona State Veterinary Medical Examining Board (“Board”)
considered this matter at its public meeting on June 15, 2022. Karla Lombana,
DVM ("Respondent") appeared telephonically on her own behalf for an
Informal Interview that was held pursuant to the authority vested in the Board
by A.R.S. § 32-2234(A} and was represented by attorney, David Stoll, Esq. After
due consideration of the evidence, the arguments and the applicable law, the
Board voted to issue the following Findings of Fact, Conclusions of Law and
Order (“Order”).

FINDINGS OF FACT

1. Respondent is the holder of License No. 6280 and is therefore authorized
to practice the profession of veterinary medicine in the State of Arizona.

2. On August 2, 2021, Respondent was doing relief work at the premises
when "“Krispin,” an 8-year-old male German Shepherd mix was presented to her
for not eating, vomiting and dehydration. This was not Complainant’s primary
care veterinary premises and only presented to the dog to University Pet Clinic

due to no appointments available with her regular veterinarian. Complainant

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reported that the dog had a history of gastrointestinal sensitivity and vomiting
and diarrhea were not uncommon,

3. Upon exam, the dog had a weight = 64.2 pounds, a temperature = 101.4
degrees, a pulse rate = 120bpm, and a respiration rate = 80bpm. Respondent
noted that the dog was quiet, dehydrated, and had a tense abdomen upon

palpation. Complainant reported that the dog may have gotten table scraps

from the grandchildren. The dog was currently on a Gi diet. Due to the dog’s
history of a sensitive stomach, Respondent suspected the dog's vomiting was
likely due to ingestion of some abnormal substance. Supportive care was
recommended and approved. The dog was administered SQ fluids and
Cerenia and discharged with Cerenia and Metronidazole tablets:

4, On August 5, 2021, Complainant picked up canned i/d diet for the dog.
The dog was still not eating normally, but had improved. Complainant stated
that in the evening a string was passing from the dog's rectum -— the string was
still connected; therefore, Complainant cut the string off at the rectum. Not all
of the string had passed. Complainant suspected that it was the embroidery
floss that went missing a month previously, approximately 16 yards. According
to Complainant, she called the premises and scheduled an appointment for
August 9th.

5. On August 6, 2021, Complainant reported that the dog had been eating
but had not passed any stool that day. It was recommended to try pumpkin in
the dog's food that day and if the problem continued, Complainant should
call. There was no mention of the dog eating embroidery thread or what

Complainant saw the previous evening.

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6. On August 9, 2021, Respondent was again doing relief work at the
premises. She asked technical staff about the dog and was advised that the
dog was not vomiting but also was not eating regularly. Respondent requested
staff to ask Complainant to bring the dog in for a recheck. At this visit,
Respondent stated that Complainant disclosed that the dog had ingested
string approximately one month prior, approximately 16 yard of embroidery
thread. After further discussion, Complainant felt it was closer to two weeks that
the dog ingested the string. Complainant also indicated that the dog had
passed the string and had not vomited for the last week and a half. According
to Respondent, Complainant did not mention having fo cut the string directly
from the rectum.

7. Upon exam, the dog had a weight = 65 pounds, a pulse rate = 120bpm,
and a respiration rate = 30rp>m; no temperature noted. Respondent noted
some discomfort upon abdominal palpation. Radiographs were performed and
did not show evidence of a Gl foreign body; therefore, exploratory surgery was
not indicated. Respondent discussed that typically string foreign bodies were
some of the more dire or serious cases, as they can cause intussusception and
other severe GI abnormalities. She was optimistic that the dog had passed
some of the string and possibly passed all of it and the dog was now dealing
with a residual IBD, or other medical sources for the vomiting. Respondent
recommended sending the radiographs out to be reviewed by a radiologist.
Complainant approved and the dog was discharged with Entice, an appetite
stimulant, until the results came back from the radiologist.

8. The following day, Respondent called Complainant to report the findings

from the radiologist. Complainant was traveling but advised the dog was a bit

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more amenable to eating that evening. Respondent told Complainant that the
radiologist did not identify a foreign body and recommended a follow up
abdominal ultrasound or referral. She mentioned that exploratory surgery was a
possibility and discussed sending the dog fo a specialist for referral and
aggressive hospitalization. Complainant was reluctant. Respondent relayed
that she would try to find an ulfrasonography service understanding that most
were booked out for weeks.

9, Respondent contacted several imaging providers and most had wait
times of greater than 10 days. She found availability through Veterinary
Sonography, ulfrasonographer, Darcie Argentina, for Thursday, April 12, 2021.
Complainant wanted to pursue an ultrasound over referral due to projected
wait times at specialty centers and finances.

10. On April 12, 2021, the dog was dropped off for the abdominal
ultrasound. Respondent discussed the case with Dr. Merker since this was her
last scheduled relief day. She advised that on the initial presentation was a
suspected foreign body of string, but it had appeared based on radiographs
that the string had passed and they were searching for other causes for the
anorexia and vomiting. Respondent also discussed the dog's medical history of
suspected foreign body ingestion with Ms. Argentina. She continued that the
dog had passed some of the string and they were optimistic that the dog
passed all of the string. Respondent provided Ms. Argentina with the report and
history from the radiologist.

11. The ultrasound was performed and the preliminary findings indicated
renal changes with possible dilation of some small bowel. Respondent was

optimistic that the dog had passed the foreign material and the ongoing

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appetite inconsistencies were due to renal changes. Ai this point, Respondent
had no further contact with Complainant. She did not see the official
ultrasound report and the case was transferred to Dr. Merker. Blood and urine
were collected and supported the dog had renal changes —- Creatinine 2.6,
BUN 41.

12. According to Complainant, when Dr. Merker discharged the dog that
evening and was asked about the string/embroidery thread, she was unaware
the dog had ingested the foreign object. Complainant was concerned that
Respondent had not sufficiently updated the ultrasonographer or Dr. Merker.
According to Dr. Merker, she was taken aback, as she was not fully aware that
the string was still an issue, given the normal radiology report. She further stated
that it was never communicated to her that the string had been cut from the
dog's anus at any time. Dr. Merker explained that she would have the
ultrasound report back in the next couple of days and this would hopefully give
them more information about what was going on with the dog. If fhe dog did
not improve, it was recommended the dog be seen at an emergency facility;
hospitalization was also discussed if the dog was not improving.

13. On August 15, 2021, Complainant reported in her narrative that the dog
was getting worse; was lethargic and in pain.

14. On August 16, 2021, Dr. Adams saw a note that the dog was not doing
well. After reviewing the medical records and the suspected renal disease, she
had staff contact the pet owner to offer SQ fluids and possible recheck. Later
that day, the dog was dropped off by Complainant's daughter since
Complainant was still out of town. The dog was reportedly worse — lethargic,

not eating or drinking. Dr. Adams examined the dog, repeated blood work (no

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azotemia}) and abdominal radiographs. Radiographs revedled severe gas
dilation of multiple areas of small bowel. Due to the concern of an obstruction
and the dog’s condition, Dr. Adams recommended exploratory surgery or
humane euthanasia.

15. Complainant relayed that the dog ate string and she had to cut the
string the dog was trying to pass and could not. After discussion of options,
Complainant elected to pursue surgery and possible euthanasia on the table
pending the findings.

16. Dr. Adams performed surgery and found a linear foreign body from the
stomach to cecum with intussusception of ileum into cecum. She was able to
remove all the foreign material with three enterotomy and gastrostomy and
reduce the intussusception. After the dog recovered from surgery, it was
recommended to transfer the dog to an emergency facility for continued
monitoring and care. The dog's prognosis was guarded.

17. Later that evening the dog was transferred to Veterinary Specialty
Center of Tucson for postsurgical monitoring and care. The dog was
hospitalized and given supportive care.

18. The following day, due to the dog's condition, the dog was humanely
euthanized.

19. The final ulfrasound report provided by Dr. Roth-Jones showed no
evidence of foreign material in the GI tract.

20. The Board found that given the dog's symptoms, history, painful
abdomen and the fact that linear foreign bodies can have negative
radiographic findings until it causes damage, Respondent deviated from the

standard of care by not performing surgery on the dog on August 9th, The

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Board noted that Respondent's failure fo timely perform surgery resulted in
major complications. The Board also noted that barium radiographs could
have been taken since there was concern that an ultrasound could not be
timely performed.

CONCLUSIONS OF LAW

21. The conduct and circumstances described in the Findings of Fact above,
constitutes a violation of A.R.S. § 32-2232(11) Gross negligence; failure to
recognize the need for surgical intervention which resulted in a delay that led
to major complications in the patient's care.

ORDER

Based upon the foregoing Findings of Fact and Conclusions of Law it is
ORDERED that Respondent's License, No. 6280 be placed on PROBATION for a
period of one (1) year, subject to the following terms and conditions that shall
be completed within the Probationary period. These requirements include three
(3) total hours of continuing education (CE) detailed below:

]. IT IS ORDERED THAT Respondent shall provide written proof satisfactory to
the Board that she has completed three (3) hours of continuing education (CE);
hours earned in compliance with this order shall not be used for licensure
renewal. Respondent shall satisfy these three (3) hours by attending CE in the
area of gastrointestinal foreign bodies. Respondent shall submit written
verification of attendance to the Board for approval prior to the end of the
Probationary period.

2. All continuing education to be completed for this Order shall be pre-
approved by the Board. Respondent shall submit to the Board a written outline

regarding how she plans to satisfy the requirements in paragraph 1 for ts

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approval within sixty (60) days of the effective date of this Order. The outline
shall include CE course details including, name, provider, date(s), hours of CE fo
be earned, and a brief course summary.

3. Respondent shall obey all federal, state and local laws/rules governing
the practice of veterinary medicine in this state.

4. Respondent shall bear all costs of complying with this Order.

5. This Order is conclusive evidence of the matters described and may be
considered by the Board in determining an appropriate sanction in the event a
subsequent violation occurs. In the event Respondent violates any term of this
Order, the Board may, after opportunity for Informal Interview or Formal
Hearing, take any other appropriate disciplinary action authorized by law,
including suspension or revocation of Respondeni’s license.

NOTICE OF APPEAL RIGHTS

Respondent is hereby notified that she has the right to request a
rehearing or review of the Order by filing a motion with the Board's Executive
Director within 30 days after service of this Order. Service of the Order is
effective five days after the date of mailing to Respondent. See A.R.S. § 41-
1092.09. The motion must set forth legally sufficient reasons for granting a
rehearing or review. A.A.C. R3-11-904. If a motion for rehearing or review is not
filed, the Board's Order becomes final 35 days after it is mailed to Respondent.
Respondent is further notified that failure to file a motion for rehearing or review
has the effect of prohibiting judicial review of the Order, according to A.R.S. §
41-1092.09(B) and A.R.S. § 12-904, et seq.

Dated this_/* day of Lequat , 2022,

Arizona State Veterinary Medical Examining Board
Jessica Creager

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Chairperson

Victoria Whitmore, Executive Director

Original of the foregoing filed this_/%__ day of CLegusst-, 2022
with the:

Arizona State Veterinary
Medical Examining Board
1740 W. Adams St., Ste. 4600
Phoenix, Arizona 85007

Copy of the foregoing sent by certified, return receipt mail
this {5 day of Cecguiat- , 2022 to:

Karla Lombana, DVM
Address on file
Respondent

this_/5_ day of Bequest, 2022 to:

David Stoll, Esq.

Beaugureau, Hancock, Stoll and Schwartz, PC
302 E. Coronado Rd

Phoenix, Arizona 85004

Board Staff

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